Bontempo, FA

Lewis, JH

Ragni, MV

Starzl, TE

English

D-Scholarship@Pitt

e fluid resuscitation in the 6,1983. )ment. Baltimore, Williams Isfusion systems (abstract). -, I 11 The Preoperative Coagulation Pattern in Liver Transplant Patients Franklin A. Bontempo, M.D. Jessica H. Lewis, M.D. Margaret V. Ragni, M.D. Thomas E. Starzl, M.D., Ph.D. INTRODUCTION The liver plays a central TOre in the maintenance of-adequate hemostasis. Among its many functions is the synthesis and degra---dation of clotting factors I, II, V, VII, IX, X, XI, XII, Fletcher, and Fitzgerald; clotting inhibitors a-I-antitrypsin (a I-A T), a-2-macroglobulin (a 2-M), and antithrombin III (AT-III); and plas-minogen. Only F VIII is an exception-both F VIIIR:Ag and F VIIIR:vW are synthesized in vascular endothelium, while the site of production of F VIII:C is unknown. When the liver suffers functional damage, particularly in advanced cirrhosis, clottrng abnormalities frequently occur, and may result in serious bleeding (1,3). When such a patient requires surgery, the presence and severity of preoperative coagulation abnormalities may lead to intraoperative bleeding (2). In liver transplantation, because the liver disease is often advanced and transfusion requirements are usually high, the €-va-luation of preoperative coagulation patterns may be -of use in predicting blood loss, gauging severity of liver disease, and initiating 135 , 136 / Franklin A. Bontempo, et al. TABLE 11.1. Categorization of Patients Diagnosis No. F M Age range PNC (post necrotic cirrhosis) 22 8 14 18-48 PBC (primary biliary cirrhosis) 18 18 0 36-59 CA (carcinoma/neoplasia) 11 7 4 21-54 SC (sclerosing cholangitis) 8 2 6 17-45 MISC (miscellaneous) 11 3 8 25-47 Totals 70 38 32 17-59 therapy. We have analyzed preoperative coagulation profiles and categorized patients according to diagnosis. In addition, we have correlated data on blood product usage with preoperative coagula-tion abnormalities and patient survival in an attempt to predict which patients are at risk for massive bleeding during transplanta-tion and for early demise. Patient Categories Patients were categorized by group as shown in Table 11.1. The post necrotic cirrhosis (PNC) group included patients with chronic active hepatitis and those with a history of hepatitis B or nonA, nonB hepatitis. The carcinoma/neoplasia (CA) group con-sisted of patients with a variety of malignant tumors and one with multiple adenomas. In the miscellaneous (MISC) category, several patients had fulminant hepatitis and the others had rare or com-bined disorders that fit neither of the previous groups. Coagulation Parameters Standard coagulation tests were performed on 64 patients preoperatively, and a coagulation abnormality score (CAS) was devised by assigning one point for each definite abnormality in the eight different test categories shown in Table 11.2. The CAS was based on a slightly more narrow definition of abnormal so that only distinctly abnormal values would be counted. The mean CAS, the mean values of the coagulation tests, and the percent abnormal for each te!?t in each diagnostic group and for all patients are also shown in Table 11.2. F 8 8 7 2 3 8 M 14 o 4 6 8 32 Age range 18-48 36-59 21-54 17-45 25-47 17-59 coagulation profiles and ;is. In addition, we have th preoperative coagula-n an attempt to predict .:ling during transplanta-as shown in Table 11.1. ) included patients with history of hepatitis B or oplasia(CA, group con-ant tumors and one with :MISC) category, several others had rare or com-~vious groups. ·-formed on 64 patients T\alit)· score (CAS) \,'35 :inite abnormalIty in the able 11.2. The CAS was on of abnormal so that ounted. The mean CAS, ld the percent abnormal for all patients are also --I I--< •• 0 0 0 •• o. 0 IX) <1' 0 r<) 0'. -0 cC"'; roi .... Y-4Nl""1'1""""i1"""'l 0-N <1'«lIX)t--.<1' 0 OcCo'.np 0' ,<!,,<!,.«lr<)r<). r<) -0 <1'N'<!'t--. r<)'<!'IX)<1'<1' 00000 ~ '""l l"'-.l t'--. ,..... C 0 - - G ('r) "D~ r-l N N Lf") ~ 0 «l1X)t--.<1'1X) Kn~roi .... o 137 l!', N o o A ... o o If) ..... v ... o A .. o o If) ..... v ... o f\ .. o o t--. o .. E .. o Z :; "" 110 c '2 .. '" E '0 c 138 I Franklin A. Bonte'mpo. et al. TABLE 11.3. Mean Values (U/ml) for Coagulation factors for Patients in Each Category and Entire Group Group No. 11 V VII IX X Xl XII PNC 20 0.33 0.35 0.27 0.43 0.56 0.44 0.65 MISC 10 0.46 0.45 0.52 0.45 0.64 0.46 0.67 SC 8 1.13 0.64 1.42 1.02 1.43 0.63 1.00 PBC 16 0.95 1.00 1.00 0.90 0.95 0.76 1.07 CA 10 0.81 1.10 0.92 1.05 0.80 1.00 1.11 Total 64 0.68 0.68 0.74 0.73 0.81 0.63 0.87 Normal for all factors = 0.50-1.50 U/ml The most frequently abnormal tests were the thrombin time (67%), antithrombin III (60%), and activated partial thromboplastin time (59%). In Table 11.3, several coagulation factors are shown to have been in the low normal range preoperatively. As can be seen in both tables, the PNC and MISC groups had more frequently abnormal tests than the other groups of patients. Intraoperative Blood Use Table 11.4 shows that intraoperatiye blood prod~ct usage wa's highest in the PNC group, followed by the SC group. The PBC and CA groups used significantly lower amounts probably because the hepatocytes are usually less abnormal in these diseases. TABLE 11.4. Blood Product Usage During 70 first Liver Transplants. Mean Values for Each Disease Category and All Nt'. rl l~rCll;D r{jfitDl1i~ R.BC FFP Pln! Pl\:C 22 58.0 55.0 31.3 MISC 11 43.7 42.1 23.0 SC 8 58.1 47.6 21.6 PBC 18 23.0 23.4 10.9 CA 11 32.6 28.5 11.5 . All 70 42.8 39.9 20.5 *Excluding the hemophiliac. ("",0 9.8* 12.5 24.3 3.9 3.3 9.3* ----------K~ .. --........ ---------------:oaguJation faciors for IUp IX ).43 ).45 l.02 ).90 1.05 )73 X 0.56 0.64 1.43 0.95 0.80 0.8] Xl 0.44 0.46 0.63 0.76 1.00 0.63 Xll 0.65 0.67 1.00 1.07 1.11 0.87 ;ts were the thrombin time ated partial thromboplastin dation factors are shown to operatively. As can be seen oups had more frequently of patients. ve blood product usage was he SC group. The PBC and )uitts probably because the in these diseases. 19 70 first Liver ;e Category and All Pial Crye 31.3 23.0 21.6 10.9 11.5 20.5 12.S 24.3 3.9 3.3 9.3* , ( } U <Xl 66t1ltlltlltll ... \j\jZZZZ I ~ ... ~ ........ o o til til til til ~~wwww II II <ul~k<ul-KoD<!D O .......... t--Nt---.t"! ..... <') ......... I I I I .... Olfltlltlltlltll ~owwww II V '"7 00-- h --u, "f.., a:. -.:. t" '<'::t r"f", N '7 C ('J 139 140 I Franklin A. Bontempo, et al. The mean usage for all first liver transplantations was 43 units for red cells, 40 for FFP, 21 for platelets, and 9 for cryo-precipitate. Survival Correlation Correlation of RBC usage and CAS with survival was signifi-cant for the patients as a group and for the PNC group specifically. Additionally, the CAS correlated significantly with RBC usage as shown in Table 11.5. The two postoperative groups in the table exclude patients who died in the operating room. DISCUSSION These findings support the contention that when widespread parenchymal liver damage occurs, as in many of the patients in the PNC and MISC groups, severe clotting abnormalities result. When large areas of normal hepatic parenchyma remain, as in bile duct disease (PBC and SC) or malignancy, normal amounts of coagula-tion factors may still be produced. The correlation between the degree of coagulation abnormality (CAS) amtRBC usage is highly significant (p = .001); in addition, patients who died in the operating room and had a higher mean CAS used more blood than those surviving the procedure. With these results in mind, immediate preoperative correction of coagu-lation defects by various means may be helpful in decreasing blood usage intraoperatively and possibly increasing survival. Studies to evaluate this are presently underway. REFERENCES 1. Ragni MV, Lewis JH, Spero JA, Hasilra U: Bleeding and coagulation abnormalities in alcoholic cirrhotic liver disease. Alcohol: elin Exp Res 6:267, 1982. . 'I "ansplantations was 43 ltelets, and 9 for cryo-'ith survival was signifi-. PNC group specifically. mtly with RBC usage as tive groups in the table groom. n that when widespread my of the patients in the lormalities result. When a remain, as in bile duct naI amounts of coagula-coagulation abnormality It (P.= ;001); ip addition, and had a higher mean .ng the procedure. With tive correction of coagu-Ipful in decreasing blood Ising survival. Studies to • Bleeding and coagulation disease. Alcohol: Clin Exp Preoperative Coagulation Pattfrtl / 141 2. Ragni MV, Lewis JH, Spero JA: Ascites-induced LeVeen shunt coa-gulopathy. Ann Surg 198:91, 1983. 3. Bontempo FA, Lewis JH, Van Thiel DH, Spero JA, Ragni MV, Butler p, Israel L, Starzl TE: The relation of preoperative coagulation findings to diagnosis, blood usage and survival in adult liver transplantation. Transplantation (in press). 

The preoperative coagulation pattern in liver transplant patients

Name not available

http://d-scholarship.pitt.edu/4076/1/31735062119767.pdf

The preoperative coagulation pattern in liver transplant patients

Abstract

Similar works

Full text

Available Versions

D-Scholarship@Pitt

Name not available

Name not available